Free wc6175 - Alaska


File Size: 171.9 kB
Pages: 1
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State: Alaska
Category: Workers Compensation
Author: BASCJAR
Word Count: 202 Words, 1,369 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.labor.state.ak.us/wc/forms/wc6175.pdf

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ALASKA DEPARTMENT OF LABOR Alaska Workers Compensation Board P.O. Box 25512 Juneau, Alaska 99802-5512

AWCB Case Number

AFFIDAVIT OF COMPENSATION RATE LESS THAN $154
2. Insurer Claim No. 3. Date of Injury

1. Employees Name (Last, First, Middle Initial)

4. Employer

5. Insurer/Adjusting Company

6. HAVING FIRST BEEN DULY SWORN, I STATE

a. I am the adjuster assigned to handle this workers compensation case. b. To the best of my knowledge, the employee has provided documentation for all the wages the employee earned in the two calendar years before injury. c. According to the employee or the employees former employers, the employee worked more than six months in the two calendar years before injury. d. Based on the wage documentation, under AS 23.30.220(a)(1) the employees gross weekly earnings are $ ___________________ and the employees weekly compensation rate is $ __________________.

7. Name of Affiant (Print or Type)

8. Affiants Signature

SUBSCRIBED AND SWORN TO BEFORE ME THIS __________ DAY OF _________________________________, 19 _________ 9. Notary Public 10. My Commission Expires:

I certify that I have mailed the original of this affidavit to the employee and a copy to the Alaska Workers Compensation Board. 11. Name of Person Mailing Affidavit 12. Signature 13. Date Mailed

ATTACH TO COMPENSATION REPORT

Form 07-6175 (Rev. 1/94)

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